From the Massachusetts Nurse Newsletter
November/December 2006 Edition
By Lee Ann Hoff, RN, PhD
and Craig Slatin, ScD, MPH
University of Massachusetts Lowell
The UMass Lowell PHASE in Health care research project has been a five-year study of health disparities among health care workers, funded by the National Institute for Occupational Safety and Health (NIOSH). The case study and focus group research addressed our questions about how health care system restructuring has affected worker health and safety. Our partnership with the MNA provided us the opportunity to learn about the working conditions nurses face in a range of health care settings. Nearly 50 MNA members, including elected leaders, local unit leaders, occupational health advocates and staff nurses, employed mostly in hospital environments, participated in a series of seven focus groups on the following topics: General health and safety; violence and abuse; diversity and discrimination issues; post-injury return to work experiences, and health care system restructuring.
Health care restructuring and nurse empowerment issues
Nurses described today’s health care system as a business model in which hospitals function like a hotel complete with ads for patients and concierge (“instead of a health care worker”) to answer questions. Entry facades resemble the “Taj Mahal... but then you enter a patient care unit and it completely drops off.” Nurses perceive money as the “bottom line” in this model, hence the emphasis on keeping patient numbers up in a desperate attempt to survive financially. Staff must “speed up, work faster, work smarter, and take up more tasks in the clinical arena.” In this restructured work environment, nurses experience a constant sense of urgency in a vicious cycle of ever increasing pace of work. They associate this environment to their increased stress levels, self-care neglect, and physical symptoms.
One nurse said this about the high-powered management model: “A lot of what’s called restructuring has nothing to do with best practice. It doesn’t have scientific evidence [to support it]. It’s really someone [chief executive, the proverbial emperor with “no clothes”] sent by the Board with an idea and saying ‘OK, there’s some goals and here’s how we’ll get to those goals.’ And if someone objects and says, ‘wait a minute, you’ve got no clothes on again’...it’s just too easy for them to say, OK, you’re not with the team. Get out. And we’ll just get some team players in here.”
Nurses also cited the systematic “downsizing, reconfiguring and outsourcing” of nursing staff through restructuring, that is, “extending nurses” by hiring cheaper health aides in schools and moving home health care patients to another agency with piecemeal billing protocols in which patients get lost in the shuffle. “And when we say stop, you need to look at this person who needs more than you’re offering [they say] Get into the real world. This is not how we do things now.”
Other evidence of restructuring is reliance on machines vs. nurses for very sick patients, plus pressure for early discharge of these sick patients. While patient acuity level is rising, staffing levels are down. Describing the impossibility of meeting care needs of two neurology patients with ventricularostomies in their heads, and trying to explain the situation to an upset family, one nurse said: “I simply can’t be in two places at one time. And they [the family] didn’t buy it, so I just said to hell with this, I’m leaving.”
Cost of restructuring
While citing financial incentives (e.g., hiring lower-paid direct care workers) that have “escalated dramatically with restructuring,” nurses say that it’s not that there is no money [for nurses’ salaries], it’s that “the money is simply oozing to the top” in the form of the salaries and bonuses paid to middle and upper management. Put another way, nurses say there is no shortage of nurses, just a shortage of those willing to work for low wages; and they describe the $10,000 bonuses to attract nurses as “stopgap measures.” Another cost (vs. financial saving) in restructured health care is the repeated introduction of new guidelines and subsequent need for continuous re-learning.
A clinical nurse specialist cited a dramatic example of “cost” to hospitals in failing to use inside nursing knowledge (vs. high-powered sales pitches from non-nurses) in management decisions before purchasing expensive equipment. That is, after “taking the doctors to dinner” and dealing with the VP for materials, “they bring me in after the sale is closed.” When she then raised questions about the item, she was told “it’s a done deal.” And then they fly in another nurse specialist “from Dallas or Minneapolis to teach us how to use it.”
One nurse used the metaphor of the “widget” to describe the cost of the manufacturing model in staff time and quality of patient care. The software computer recording of patient care was meant to document that nurses “managed care” in an “efficient” way to bill for and not be denied payment. Nurses noted that the computer software does not allow one “to override the system to put in your assessment, what you saw. You could only do the checking off…that you had the patient turn, cough, and deep breathe”—leaving no place for “nursing judgment.”
This underscores the misguided application of the manufacturing model in which “the widget is always the same,” whereas in healthcare, every patient is different. One nurse stated: “We’ve been sold out by those nurses who became business managers” who apply the concept of the widget as though every patient is the same, thus by-passing the reality of “whole patient ambience.”
Besides these costs of provider reorganization resulting from restructuring, nurses described the pain of nurse managers who must implement layoffs. In one VNA, for example, the entire home health aide Departments (mostly ethnic minority workers who lost all benefits) was eliminated because it was “a money loser.” Cynicism from these actions combines with apathy: “The [nurses] who have tolerated it for a long time just accept it ... the norm is we don’t speak up because you don’t bite the hand that feeds you... The women are much more apathetic the longer they are in a system, and new people who won’t tolerate it just leave.” Contract workers—hired to replace professional and other workers who have been let go or simply quit—are thought to have no buy-in or incentive for institutional loyalty in job performance.
Injury prevention: unions and other sources of support
Nurses cited the National Institute for Occupational Safety and Health (NIOSH) as a source of support with its “guidelines” for injury prevention, although these are not enforceable. Most importantly, they singled out the MNA union for the “very powerful role” it plays in acting on behalf of injured workers and injury prevention such as through protective contracts, its legislative agenda for safe staffing, and changing legal definitions which originally excluded nurses as objects of felonious assault.
The union “gives the individual nurse and smaller groups of nurses the support of their colleagues ... the ability to say no [to effects of restructuring]. We’re here to take care of patients. That’s our legal responsibility...and that’s why you’re getting paid to resist some of these foolish changes and bring forth some things that do help patients.” This nurse said being organized is a tremendous asset to the health care environment, and offers the satisfaction of being able to say “enough is enough and having the union say, this is what the agreement is.”
Nurses also discussed whistle-blower protections, intimidation and the difficulty of fighting the system. A nurse who had worked with several nurse managers over 15 years said that those who “try to work with the system ... and try to prove things and stand up and advocate for nurses and patients, are the ones that ended up being pushed out the door.”
In one way, the nurses’ voices about workplace health and safety speak very powerfully for themselves, providing a vivid data-based rationale for whatever action nurses and others may wish to take on behalf of themselves and fellow health care workers and—by extension—improving the quality of patient care.
Emerging from qualitative analysis is the overarching theme of health care restructuring in which health care agencies are redefined as businesses, patients are redefined as “widgets” in a factory-like line of production, and service delivered to these “widgets” is redefined as a commodity. Together, the re-definitions central to restructuring reveal that profit margins supersede concerns about and investment in basic training programs and policy implementation to protect the health and safety of health care workers. The reality of health care restructuring is often the giant invisible to workers on the ground that are faced with the grind of daily duty, engrossed in demands, rescue strategies, and survival of themselves and patients.
We learned that the health and safety of nurses and other health care workers is often disregarded as a priority in many health care agencies. Where MNA members have been able to work with concerned managers, wonderful progress has been made in health and safety of workers, for example, in one hospital system’s nationally acclaimed model for violence prevention.
By and large, though, we learned that health care facility owners, the various payers who demand full health care service for reduced costs, and the workers’ compensation insurers and government agency have failed to see the importance of protecting employees’ health and safety, and at worst have established a system to evade the employer’s legal responsibility to provide a healthy and safe workplace.
Patient safety concerns are primary, yet owners and managers fail to recognize that patient safety is dependent upon health care worker safety. Instead of implementing comprehensive health and safety programs, nurses and other workers are blamed for their injuries and illnesses, and patients are considered the unavoidable cause of injury risks–they are too heavy, too old, or have dementia, and nurses have to accept the consequences of these patients’ behavior as part of the job. But fortunately, the MNA counters these arguments and beliefs and points out that increased staffing, better working conditions, making both worker and patient health and safety a system-wide priority, and giving voice to nurses’ collective knowledge can and will make health care work safe and effective.
We have deep appreciation for the opportunity that the MNA and focus group participants provided us to learn about these health care issues. As our analysis is completed and we publish our findings, we hope to provide support to the movement for creating a health care system with universal access, affordability, high quality, and working conditions that reflect the dedication and commitment of nurses and all health care workers.
Acknowledgements to: MNA member focus group participants; focus group coordinator Evie Bain and PHASE team members Eduardo Siqueira, Kathy Sperrazza and Beth Wilson for their assistance with this research.
About the authors: Lee Ann Hoff is a nurse-anthropologist, has authored several books on crisis and violence and is a co-investigator of the UMass Lowell PHASE research project. Craig Slatin is principal investigator of the PHASE project and associate professor at UMass Lowell. For methodological facets of this project contact: firstname.lastname@example.org.